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SAN JOACUE NTY PUBLIC HEALTH SERVICES - ENVIRONMENTA TH DIVSION <br />ERGROUND STORAGE TANK PROGRAM - FEE WORKS <br />SFACILITY <br />SITE NAME <br />FACILITY CONTACT NAME <br />T <br />0l <br />/� <br />TWO GU S <br />OAJ 11 e IA r YZo <br />I <br />E <br />FACILITY ADDRESS <br />y- 1-, -o <br />14- 7 E <br />SITE PHONE i with AREA CODE <br />R® d <br />& <br />R <br />cL ( Y <br />Q ® O q <br />A <br />CITYST,tATE <br />' 'L <br />O <br />ZIP CODDE^� # of TANKS / <br />�/a I �J✓ ® at SITE <br />e <br />lel W e <br />PIAPPLICANT/BILLING <br />L <br />NAME <br />CO y17®y^ rL c o rs <br />APPLICANT CONTACT NAME -p- <br />m"0. l <br />Y <br />// <br />-T7, c. G o G I <br />C <br />MAILING ADDRESS <br />d <br />APPLICANT PHONE # WITH AREA CODE <br />N <br />1>v�,ve. <br />®� �1-G 338 <br />T <br />CITY <br />SC. <br />( o 71, <br />I STATE <br />I <br />ZIP CODE <br />,j ' <br />TYPE of APPLICATION <br />(Closure, Installation, etc.) <br />TOTAL <br />C <br />PERMANENT CLOSURE (Removal or Authorized Closure- in-Ptace)I TANK I.D. #(s) <br />L <br />0l <br />CLOSURE FEE = 578.00/hour (3 hours minimum/TANK) # TANK(s) X 3234.00 = <br />$ <br />S <br />Ul <br />TEMPORARY CLOSURE (Plan Review & Inspections) TANK I.D. #(s) <br />R <br />E <br />TEMPORARY CLOSURE FEE = 578.00/hour (3 hours minimum/FACILITY) I $234.00 minimum <br />$ <br />P1 INSTALLATION PLAN CHECK (Plan Review & Construction Inspections) TANK I.D. #(s) <br />L, <br />A <br />N PLAN CHECK FEE _ $78.00/hour (8 hours minimum/FACILITY) _ $624.00 minimum <br />$ <br />M TRANSFER FEE = $20.00 UNAUTHORIZED RELEASE EVALUATION = $78.00/hr ' $ <br />I <br />S I <br />Cl CONSULTATION FEE _ $78.00/hr I SAMPLING INSPECTION FEE = 578.00/hr ( $ <br />TOTAL DUE $ 3 �® p® <br />FOR OFFICE USE ONLY <br />SWEEPS # COMPUTER # LOC CODE <br />EH 23 032 (REVISEED 5-27-97) <br />DIST CODE I AMOUNT RECEIVED I CHECK #/CASH I RECEIVED BY <br />�S I <br />DATE RECEIVED <br />